Volunteer Registration Form - Class A - Special Olympics North Dakota
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1
2VOLUNTEER REGISTRATION FORM-CLASS A
Part I – General Information
ALL INFORMATION IS REQUIRED UNLESS INDICATED AS OPTIONAL (Please Print)
Last Name:
First Name:
Middle Name:
Address:
City:
County:
State:
Zip Code:
Social Security No:
Birth date (mm/dd/yy):
Gender:
Male
Female
Daytime Phone: ( )
Evening Phone: ( )
Email:
Employer/School:
Occupation:
Emergency contact:
Emergency Phone: ( )
Part II – Background Information
Please answer the following questions:
Do you use illegal drugs?
Yes
No
Have you ever been convicted of a criminal offense?
Yes
No
Have you ever been criminally charged with neglect, abuse or assault?
Yes
No
Has your driver's license ever been suspended or revoked?
Yes*
No
*If yes, please provide: Driver’s license number ________________ State issued___________
Have you ever been adjudged liable for civil penalties or damages involving sexual or physical
Yes
No
abuse?
Have you ever applied to, volunteered, participated as a Special Olympics athlete or been
Yes
No
employed by any Special Olympics organization?
If you answered YES to any of the above please explain (use additional sheets of paper if necessary):
Part III – Additional Information
Please list two references 18 years of age or older who are not related to you (for volunteers under 18 years
of age):
1. Name:_______________________________________________________________________________
Complete Address: ___________________________________________________________________
Home Phone Number: (_____)________________ Work Phone Number: (____)________________
Email Address (optional)_____________________
2. Name: _______________________________________________________________________________
Complete Address: ___________________________________________________________________
Home Phone Number: (
) ________________Work Phone Number: (
)__________________
Email Address (optional) ______________________
By providing the above references, I am authorizing Special Olympics to contact them in reference to my
volunteer application.
(over)
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